MEDICARE: ANTIAGING CENTERS OF TEXAS MDPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083P0901X	Public Health & General Preventive Medicine Physician

General Provider Information

NPI Number	:	1043409881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTIAGING CENTERS OF TEXAS MDPA

Provider Business Mailing Address
First Line	:	5318 WESLAYAN ST # 183
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-1048
Country	:	US
Telephone Number	:	713-589-9115
Fax Number	:	281-201-4560

Provider Business Practice Location Address
First Line	:	2646 S LOOP W STE 300
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2678
Country	:	US
Telephone Number	:	713-589-9115
Fax Number	:	281-201-4560

Authorized Official
Title or Position	:	AUTHORIZED OFFICER
Name	:	MRS. AJAY K AGGARWAL
Credential	:
Telephone Number	:	877-433-4352

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	12/04/2008

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